Healthcare Provider Details

I. General information

NPI: 1851391148
Provider Name (Legal Business Name): OUR LADY OF THE LAKE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7777 HENNESSY BLVD SUITE 6000
BATON ROUGE LA
70808-4300
US

IV. Provider business mailing address

7777 HENNESSY BLVD SUITE 6000
BATON ROUGE LA
70808-4300
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-8648
  • Fax: 225-765-7898
Mailing address:
  • Phone: 225-765-8648
  • Fax: 225-765-7898

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: TAMARA WHITE
Title or Position: DIRECTOR OF BUSINESS SERVICES
Credential:
Phone: 225-765-4251